Patient health management programs attempt to improve the care of populations by conducting continuous measurement and feedback of outcomes (Montague et al. 1997). These programs aim to identify populations at risk, implement interventions to overcome identified barriers to optimal care and measure relevant outcomes (Epstein and Sherwood 1996; Cox 1999). The outcomes encompass more than traditional measurements of morbidity and mortality to include "soft" but highly relevant patient-specific outcomes such as quality of life and patient satisfaction (Epstein and Sherwood 1996). The goal of patient health management programs is to address care gaps that exist between the efficacy data and its most advantageous use in the target populations that arise largely in response to a breakdown in the flow of knowledge (Montague et al. 2002). The natural consequence of a care gap is inefficient utilization of scarce healthcare resources, and in some cases, suboptimal clinical results for patients and an increase in costs to the system (Montague et al. 1997). As society struggles with escalating healthcare costs, and a general increase in the prevalence, as well as the morbidity of common chronic conditions, such as asthma and diabetes, patient health management programs offer new opportunities to improve the process of care, create efficiencies in the healthcare system and enhance the outcomes of patients suffering from these conditions.
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